Could the autonomic arousal that accompanies anxiety contribute to cardiovascular instability?

Women with histories of full-blown panic attacks had elevated risks for coronary heart disease.

To find out, these investigators extracted data from the Myocardial Ischemia and Migraine Study, a prospective, community-based study of 3369 generally healthy women (age range, 51–83). Most of the data were obtained from questionnaires, which were supplemented by physical examination and ambulatory EKG monitoring and by individual follow-up or event confirmation of patients who had died or been hospitalized for serious cardiovascular events.

Full-blown panic attacks were defined as sudden fear, anxiety, or extreme discomfort accompanied by four or more DSM-defined panic attack symptoms. A total of 330 patients reported experiencing full-blown panic attacks over the 6 months before the study, and 273 had experienced limited-symptom panic attacks (anxiety plus 1–3 panic attack symptoms).

Researchers determined risk for coronary heart disease (CHD, defined as myocardial infarction or cardiac death) after adjustment for all relevant risk factors, including smoking, hypertension, body-mass index, depression history, and physical activity. The risk for subsequent CHD was 4.2 times higher in women who had experienced full-blown panic attacks than in those without panic histories. Women with limited-symptom attacks did not have significantly elevated risks for subsequent CHD (but did have elevated risks for stroke and all-cause mortality). Depression was not associated with cardiovascular events after adjustment for panic attacks.

Comment: It is not clear whether panic attacks are a manifestation of autonomic instability that predisposes to cardiac events or whether the physiology of panic anxiety brings out latent coronary instability. In either case, panic attacks in postmenopausal women appear to be an independent risk factor for CHD. Patients having panic attacks with or without panic disorder should be evaluated for comorbid CHD. It will take some creativity to explain these findings to patients while working to reduce catastrophic reactions to perceived dangers.

— Steven Dubovsky, MD

Published in Journal Watch Psychiatry October 29, 2007